MA Problem Gambling Specialist (MA PGS) Certificate This is the form for the MA PGS certificate application (MA PGS, MA PGS I, and MA PGS II). "*" indicates required fields Step 1 of 6 – Personal Information 16% Which track of the Massachusetts Problem Gambling Specialist (MA PGS) certificate are you applying for?* MA PGS (Associate’s degree & 2.5 years of addiction-related supervised experience; or High school diploma & 3 years of addiction-related supervised experience) MA PGS I (Bachelor’s degree & 2 years of addiction-related supervised experience) MA PGS II (Master’s and/or doctoral degree & 1 year of addiction-related supervised experience & Massachusetts licensure) Name* First Last Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone number*Email* Current Employer*Job Title*Work Address (Agency, Organization or Private Practice)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If you would like to receive a physical copy of your MA PGS certificate at no cost, please choose your preferred address below:* Home Address Work Address N/A – a digital copy of the certificate works for me Which category of certification are you applying for*Payment information will be collected at the end of the application. First time registration ($50 fee) Registration renewal ($25 fee) Lapsed registration renewal ($75 fee) Highest degree earned and name of issuing institution*Credentials*Please briefly describe your addiction-related experience. (100 word count)*Please upload your resume (as a PDF), inclusive of professional, addiction-related experience.*Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 10 MB.Please upload documentation (as a PDF) to confirm that you have completed the required 30 continuing education credit hours of gambling specific coursework through M-TAC and/or PBU (completed coursework may include live trainings and/or on-demand courses).*E.g. CE Certificates earned from M-TAC and/or PBU trainings and courses. Certificates can be downloaded from your M-TAC profile. Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. Please upload documentation (as a PDF) to confirm that you have completed the required 15 continuing education credit hours of gambling specific coursework through M-TAC and/or PBU (completed coursework may include live trainings and/or on-demand courses).*E.g. CE Certificates earned from M-TAC and/or PBU trainings and courses. Certificates can be downloaded from your M-TAC profile. Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 10 MB. Proof of continued clinical supervision regarding problem gambling is required for MA PGS II and MA PGS III certificate applicants. This requirement is not necessary if you currently work as a clinical supervisor or are a licensed, independent practitioner in private practice. If you are not currently receiving clinical supervision for problem gambling treatment, submission of a letter confirming that you are receiving supervision on other addiction-related casework is required. Please select one statement below:Are you a clinical supervisor?* Yes No Are you an independent practitioner in a private practice?* Yes No Supervision Requirement for both first-time applicants and renewals. This requirement is not necessary if you currently work as a clinical supervisor or an independent practitioner in private practice. Please provide a letter from your supervisor stating that you receive regular clinical supervision and that problem gambling issues will be discussed as they arise with clients. If you are not currently receiving clinical supervision on problem gambling treatment, please submit a letter stating that you receive supervision on other addiction-related cases.*Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 10 MB.The letter must contain: 1) A description of the applicant’s direct contact with supervision regarding gambling disorder and/or addiction cases. (Group or individual supervision is allowed, but time spent in staff or administrative meetings is not.) 2) A description of the supervised work position and work setting/program during the clinical supervision. 3) The supervisor’s signature and/or sign-off on the supervision. 4) The supervisor’s professional qualifications Supervision Requirement for both first-time applicants and renewals: Applicants are not required to receive ongoing supervision on problem gambling. Yet, you are still required to submit a letter stating that you have recently received supervision on problem gambling or other addiction supporting services (Bachelor's degree & 2 years of supervised experience; Associate's degree & 2.5 years of supervised experience; or High School Diploma & 3 years of supervised experience). If you are currently receiving supervision, please include a letter from your current supervisor.*Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 10 MB.The letter must contain: 1) A description of the applicant’s direct contact with supervision regarding gambling disorder and/or addiction supporting services. (Group or individual supervision is allowed, but time spent in staff or administrative meetings is not.) 2) A description of the supervised work position and work setting/program during the supervision. 3) The supervisor’s signature and/or sign-off on the supervision. 4) The supervisor’s professional qualifications Please upload a letter from your place of employment certifying your position and role as a clinical supervisor or a copy of your independent license showing you are in good standing*Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 10 MB. I agree to these ethical codes below:* I agree to the code of conduct listed below I will support all personal and professional efforts toward a primary goal of recovery for myself, the client and their family. I will be and remain committed to the highest quality therapeutic care for those who seek my professional services. I will contribute myself and my work to the best interest of my client and their needs. I will preserve an objective, professional relationship with the client at all times and use my clinical supervision resources if this relationship falls out of balance. I will follow the laws and regulations pertaining to the confidentiality of all records, material and knowledge concerning the client and equal service to all clients. I will adhere to all policies and management functions within my institution, and advance said policies and functions with my clients. I will continue to assess my own personal strengths, limitations, biases and effectiveness regularly and understand my responsibility for professional growth through further education and training. I will manage my own conduct in all areas, including use of gambling, alcohol and other drugs and other addictive behaviors. I will only state any personal capabilities or professional qualifications actually gained. I will not impose my own view on gambling or any issues related to gambling on my clients. Disciplinary HistoryHas any disciplinary action been taken against you by a licensing/certification board located in the United States or any country or foreign jurisdiction?* Yes No Are you the subject of pending disciplinary action by a licensing/certification board located in the United States or any country or foreign jurisdiction?* Yes No Have you voluntarily surrendered or resigned a professional license (does not include non-renewal or expired licenses) to a licensing/certification board in the United States or any country or foreign jurisdiction?* Yes No Have you ever been denied a professional license in the United States or any country or foreign jurisdiction?* Yes No If you answered "yes" to any of the above questions, please explain:*CONSENT TO RELEASE OF INFORMATION* I consent to the information release below By checking the box above and providing your digital signature, you are consenting to the following: I give permission to HRiA to request information from my present and past employers, and any institution or agency with which I am or have been associated. Information may be obtained from any individual (from my associations shared in this document), to determine my professional competence and accomplishments. I consent to HRiA inspecting any documents or records necessary to determine my “acceptable standard” to receive the MA PGS certificate. I hereby release from any liability all representatives of HRiA and all individuals and organizations who provide information to HRiA while acting in good faith, to determine my credentials. I am aware that any false or misleading information deliberately given will be considered a serious matter, and will be dealt with accordingly. I understand that this release expires one year from the signature date. Would you like to receive referrals for your agency, organization, or private practice from M-TAC and the MA Problem Gambling Helpline?* Yes No Please provide the following referral information* Contact information for problem gambling treatment or support (name of agency, private practice, organization; website, if applicable; email address and phone number). Other important referral information. Some clients may prefer to seek help from professionals who share their own gender identities. Please share your gender identity, if you are comfortable doing so.Some clients may prefer to seek help from professionals who share their own race/ethnic identities. Please share your race/ethnic identity(ies), if you are comfortable doing so.What language(s) do you speak?*Please list payment options: (i.e. insurance taken, sliding scale, set fee, etc.)*Days/hours that you offer treatment or support services*I currently maintain professional liability insurance. Yes No Name of insurer:Please submit a copy of your practice or organization's liability insurance.Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 10 MB.Do you also treat or support family members of clients who experience problem gambling?* Yes No Other relevant specialties? If so, please list them below. Digital Signature*By signing your name in the box below, it is the same as a wet signature on a legal document. I certify that all answers above are truthful to the best of my knowledge. Date MM slash DD slash YYYY New Registration Price: Registration Renewal Price: Lapsed Registration Renewal Price: Credit Card NameThis field is for validation purposes and should be left unchanged.